Student Immunization Form

Saint Louis University Student Immunization Record Web Form

Instructions

Please complete by:

August 1 for Fall SemesterDecember 1 for Spring SemesterMay 1 for Summer SemesterSubmissions of this record, by the date specified, is mandatory. Failure to comply will result in registration being cancelled and/or restricted.

Printable version: Please use and return by mail if the form is to be filled out by your physician. Return forms to:

Please respond to the following, which summarize the immunization requirements for Saint Louis University.

1. The Student has completed a primary series of diphtheria and tetanus immunization.

2. The Student has had a tetanus booster within the past ten years

3. The Student has received at least one dose of Rubella and Mumps vaccines

If No, is there documentation of physician-diagnosed illness(mumps ), or laboratory evidence of immunity(rubella , mumps )?Please contact the Student Health Center for instructions how to submit documentation for above responses, 314-977-2323

4. The student has received two doses of measles vaccine (alone or in combination) on or after first birthday.

If No, is there documentation of physician diagnosed illness or laboratory evidence of immunity Please contact the Student Health Center for instructions how to submit documentation for above responses, 314-977-2323

5. The student has had a negative tuberculin test within the past 12 months

Physician/Clinic Name

Address

Date

Exemptions

Students claiming exemption from immunizations because of medical contraindications must submit a written statement signed and dated by a physician

Students claiming exemption from immunizations because of religious beliefs must submit a written statement, signed and dated by the student (or parent/guardian if the student is a minor) describing his/her objection to immunization based upon bona fide religious beliefs or practice.

Personal Health History

Student Last Name:

Banner ID

1. Please list any significant Health Problems.

2 List any medications you take on a regular or frequent basis.

3 Are you allergic to any medications?

3b) If Yes, please list.

4. Do you have any other kinds of allergic conditions such as asthma, hay fever, etc?

4b) If yes, please list.

5 List any significant past health problems.

6. Have you ever been hospitalized?

6b) If Yes, indicate why and when.

7. Have you ever had a head injury, concussion, broken bones or other serious injury?

Diphtheria and Tetanus: Documentation of primary series of diphtheria and tetanus toxoid, and a booster with the past ten years

Measles: Documentation of two doses of live measles (or MMR combined) vaccine separated by at least one month on or after the first birthday, or, documentation of physician-diagnosed disease or laboratory evidence of immunity. Because routine childhood immunization schedules for two doses of Measles vaccine have only recently been implemented most students now entering the University will need the second dose of live measles vaccine. Individuals who received killed measles vaccine, combination of killed and live measles vaccine, or measles vaccine of an unknown type in the period 1963-1978 are considered unvaccinated, and should receive two doses of live vaccine at least one month apart.

Mumps: Documentation of one dose of live mumps (or MMR combined) vaccine on or after the first birthday, or, documentation of physician-diagnosed mumps or laboratory evidence of immunity. Persons who received killed mumps vaccine which was available between 1950-1978 might benefit from revaccination.

Rubella: Documentation of one dose of rubella (or MMR combined) vaccine on or after the first birthday, or, documentation of laboratory evidence of immunity.

Varicella: Documentation of two doses of live varicella vaccine separated by at least one month, or documentation of physician-diagnosed disease or laboratory evidence of immunity or birth in the U.S. before 1980.

Meningitis: Immunization is required for all freshmen students living in residence halls or signed waiver acknowledging risks/ benefits of vaccine.

International students born in a country with a high incidence of tuberculosis.

Students with a history of living or traveling for more than 2 months in areas with a high incidence of tuberculosis disease.

Students with signs or symptoms of active tuberculosis, a positive tuberculosis skin test or close contacts with a person known to have active tuberculosis.

Students who have worked in nursing homes, hospitals, or other residential institutions.

Polio: Polio vaccine is not routinely given to adults, and therefore students are not required to receive a booster or a primary series if they were not previously immunized. Students should, however, document their childhood polio vaccine immunization. In the unlikely event of epidemic disease, special requirements may be instituted.

Hepatitis: Immunization against Hepatitis B is strongly recommended for all students and is required for health professions student prior to their clinical assignments.

Applicability, Documentation and Enforcement

This policy applies to all domestic and international students entering the University for the first time, unless medical or religious exemptions pertain. Students in the School of Professional Studies must only comply with the requirement related to tuberculin testing.

Submissions of this record, by the date specified, is mandatory. Failure to comply will result in registration being cancelled and/or restricted.

The University also reserves the right to deny access to campus facilities, including residence halls, if documentation of compliance has not been provided. Further, in accordance with public health recommendations, non-immune students may be excluded from the university campus in the event of a measles, rubella, mumps or diphtheria outbreak or other public health recommendation.

Authorization for Release of Immunization Data

I authorize Saint Louis University to release this immunization record to public health authorities for compliance audits and/or in the event of a health or safety emergency, and to health care providers and institutions to which I may be assigned during my educational experience if I choose a health professions related major.

Clicking the submit button will be considered a digital signature on this form.